Mandatory food fortification with folic acid
Authors: Anita Kar, C S Yajnik, P P Doke, Prajkta Bhide, Amruta Chutke, Bhagyashree Radhakrishnan, Supriya Phadnis
Journal: The Lancet Global Health (2022)

We would like to point out two issues of major concern in the Health Policy paper by Vijaya Kancherla and colleagues (July 2022).1Kancherla V Botto LD Rowe LA et al.Preventing birth defects, saving lives, and promoting health equity: an urgent call to action for universal mandatory food fortification with folic acid.Lancet Glob Health. 2022; 10: e1053-e1057Summary Full Text Full Text PDF PubMed Scopus (33) Google Scholar The paper calls on the World Health Assembly to ensure universal mandatory food fortification with folic acid for prevention of birth defects. The use of the term birth defects in the title is misleading, as this umbrella term includes a large spectrum of congenital disorders, few among which are folate sensitive. By linking folate-fortified foods with the term birth defects, the title erroneously suggests that folate-fortified foods can prevent all congenital anomalies. The title is also discordant with the body of the paper, which discusses the prevention of two low-prevalence conditions—spina bifida and anencephaly—without referring to other folate-sensitive congenital anomalies (eg, cardiac anomalies, orofacial clefts, limb defects, hydrocephalus, and urinary tract anomalies).2Wilson RD O'Connor DL Maternal folic acid and multivitamin supplementation: international clinical evidence with considerations for the prevention of folate-sensitive birth defects.Prev Med Rep. 2021; 24101617PubMed Google Scholar The second issue is that, by calling for universal fortification, the paper fails to contextualise prevention of birth defects in the resource realities of low-income and middle-income countries (ie, only women in the preconception and interconception period are targeted, rather than the entire population). The authors overlook realities of poor access to food and diet diversity, cultural practices, and costs of fortification. WHO has recommended the universal adoption of preconception care.3Lassi ZS Kedzior SG Tariq W Jadoon Y Das JK Bhutta ZA Effects of preconception care and periconception interventions on maternal nutritional status and birth outcomes in low- and middle-income countries: a systematic review.Nutrients. 2020; 12: 606Crossref Scopus (24) Google Scholar A comprehensive preconception package, including micronutrient (iron, folate, and B12) supplements, screening, and education of beneficiaries, delivered through the primary health-care system, would address a whole gamut of birth outcomes4Bhide P Kar A Prevalence and determinants of folate deficiency among urban Indian women in the periconception period.Eur J Clin Nutr. 2019; 73: 1639-1641Crossref PubMed Scopus (5) Google Scholar and would be a better alternative to the costly and culturally questionable strategy of mandatory food fortification. Women of reproductive age in India have a high prevalence of folate and vitamin B12 deficiency.5Behere RV Deshmukh AS Otiv S Gupte MD Yajnik CS Maternal vitamin B12 status during pregnancy and its association with outcomes of pregnancy and health of the offspring: a systematic review and implications for policy in India.Front Endocrinol (Lausanne). 2021; 12619176Crossref PubMed Scopus (47) Google Scholar The strong biological association between vitamin B12 and folate metabolism argues against food fortification with only folic acid. Although we believe that folate fortification of foods should be encouraged where feasible, mandating universal folic acid flour fortification across the world is not advisable. We request the authors to consider clarifying and revising the title by replacing the term birth defects with spina bifida and anencephaly. We declare no competing interests. Preventing birth defects, saving lives, and promoting health equity: an urgent call to action for universal mandatory food fortification with folic acidJuly 20, 2021 marked the 30th anniversary of the publication of the landmark trial by the British Medical Research Council showing unequivocally that maternal intake of folic acid (vitamin B9) starting before pregnancy prevents most cases of infant spina bifida and anencephaly—two major neural tube defects that are severe, disabling, and often fatal. Mandatory food fortification with folic acid is a safe, cost-effective, and sustainable intervention to prevent spina bifida and anencephaly. Yet few countries implement fortification with folic acid; only a quarter of all preventable spina bifida and anencephaly cases worldwide are currently avoided by food fortification. Full-Text PDF Open AccessMandatory food fortification with folic acidIn their Health Policy paper, Vijaya Kancherla and colleagues1 ask the World Health Assembly to pass a resolution for universal mandatory folic acid fortification. Such an approach would reduce the incidence of neural tube defects, but it would certainly not eliminate them because there are other causes besides low folate status, including low vitamin B12 status and maternal obesity. The authors dismiss potential harms as concerns of the past and ignore a growing evidence base of harms in the post-fortification era. Full-Text PDF Open AccessMandatory food fortification with folic acid – Authors' replyIn their Correspondence in response to our call to action for a World Health Assembly (WHA) resolution on mandatory food fortification with folic acid,1 David Smith and colleagues express concerns about the safety of folic acid fortification, while Anita Kar and colleagues question the applicability of food fortification as a global prevention strategy for spina bifida and anencephaly. Full-Text PDF Open AccessMandatory food fortification with folic acidWe agree with Vijaya Kancherla and colleagues,1 in their Health Policy paper, that mandatory food fortification programmes promote health equity. The authors make a compelling case for the World Health Assembly to pass an urgent resolution for universal, mandatory food fortification with folic acid. We believe that this urgent need applies equally to calcium. The consequences of calcium deficiency disproportionately affect pregnant women from low-income communities,2 among whom morbidity and mortality from pre-eclampsia is one of the most striking health inequities globally. Full-Text PDF Open Access